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	<h1 class="title">Welcome to Ailment Wiretapper</h1>
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	    <table width="646" height="166" border="0">
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            <td width="255" height="162" valign="top"><img src="images/img07.jpg" alt="" width="114" height="114" class="left" /></td>
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               <legend class="style1">Sample Form</legend>
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                     <td width="83" height="27"><strong>First Name</strong></td>
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                     <td height="28"><strong>Last Name</strong></td>
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                       <input type="password" name="textfield2" id="textfield2" />
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                     <td height="27"><strong>Address</strong></td>
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                     <td height="7">                                          </td>
                     <td></td>
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                       <input type="submit" name="button" id="button" value="Register" />
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